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Migratory Stomatitis – Case Presentation Romanian Journal of Oral Rehabilitation Vol. 10, No. 4 October- December 2018 MIGRATORY STOMATITIS – CASE PRESENTATION Ana Maria Filioreanu¹, Cristina Popa¹*, George Alexandru Maftei¹,Ioanina Parlatescu², Carmen Larisa Nicolae², Eugenia Popescu³ 1Oral Medicine Discipline, Faculty of Dental Medicine, “Grigore T. Popa” University of Medicine and Pharmacy Iasi 2 Oral Medicine Discipline, Faculty of Dental Medicine, “Carol Davila” University of Medicine and Pharmacy Bucuresti 3 Oral Surgery Discipline, Faculty of Dental Medicine, “Grigore T. Popa” University of Medicine and Pharmacy Iasi *Corresponding author.Email: [email protected] Abstract Migratory stomatitis is a rare recurring condition of unknown etiology that mainly involves lingual mucosa, with a typical appearance of geographic tongue. Factors such as heredity, nutritional deficiencies or stress may be the contributing factors to the appearance of lesions. Clinically, they appear as circular, multiple, erythematous lesions with red spots surrounded by a white, narrow, hyperkeratotic aspect with irregular, slightly elevated appearance modifying its form in 24 hours.The condition may have spectacular clinical signs when the lesions are localised on the tongue, and may involve other areas of oral mucosa, such as labial or floor of mouth mucosa. The aim of this study is to present a clinical case of a patient with two localisations of lesions corresponding clinically to migratory stomatitis. The anatomopathological examination confirmed the migratory stomatitis diagnosis, so we could begin the specific treatment, to which the patient responded positively. Key words:migratory stomatitis, geographic tongue, geographic stomatitis Introduction through active and remission phases (geographic tongue - with no manifestations Migratory stomatitis is a tissue modification in other areas of oral mucosa); Type 2: of the oral mucosa that usually starts in geographic tongue, accompanied by lesions childhood, with autosomal dominant also located in other areas of oral mucosa; transmission and benign evolution[1, 2]. It Type 3: lesions involving lingual mucosa, clinically manifests in spikes. The with unusual appearance accompanied by reactivation is conditioned by stress, depapillations of oral mucosa in different emotional states, neighbouring infections localisations; Type 4: circinate lesions with a (dento-gingival, pharyngeal), or related to typical appearance and unusual localisation general pathology diseases. [1,3,4]. (involving different areas of oral mucosa, but In most cases, lesions begin on the dorsal less the tongue surface), clinical signs vary face of the tongue and then coexist with the and it is difficult to recognize the lesion [5]. lesions located in other topographical areas This study presents a case of migratory of the oral mucosa. Hume divided migratory stomatitis, in which, due to atypical stomatitis into types: Type 1: lesions on the distribution of the lesions, it could be easily dorsal face, edges and tip of the tongue, with confused with other pathological entities. their possible extension to the ventral lingual Clinical case face; lesions could migrate over time and go 54 Romanian Journal of Oral Rehabilitation Vol. 10, No. 4 October- December 2018 The patient MZ, male, aged 37, visited the Maxillofacial Surgery Outpatient Clinic of “Sf Spiridon” County Emergency Hospital in Iasi, complaining of fatigue and discomfort in the dorsal face of tongue and palatine mucosa, with mastication and swallowing functional disorders. From an anamnestic and symptomatic point of view, the patient reported that he had not observed earlier any lesions or subjective pain (burning sensation). Fig.2 Migratory glossitis. 4 days from onset. Fig.3 Migratory stomatitis, 3 days from Fig.1 Migratory glossitis. 3 days from onset onset. 55 Romanian Journal of Oral Rehabilitation Vol. 10, No. 4 October- December 2018 using the diagnoses for other conditions with similar clinical signs. The differential diagnosis includes: psoriasis, oral lichen planus, acute oral candidiasis, erythroplakia, discoid or systemic lupus erythematosus, reactive ulcerative lesions and drug allergies. To perform the anatomopathological examination, bioptical samples were taken from the dorsal face of the tongue. Histopathological results showed in the epithelial tissue: parakeratosis and absence of granulous layer, acantosis of the spinous layer especially in suprabasal upper layer and pseudoepiteliomatous hyperplasia; in the superficial chorion, presence of inflammatory infiltration rich in lymphocytes, macrophages and neutrophils. The white area of the lesion presents on the Fig.4 Migratory stomatitis, palatine mucosa. surface of necrotic epithelial cells and an A detail. inflammatory infiltration predominantly composed of neutrophils in the superficial Intraoral clinical examination showed the chorion. The erythematous area of the lesion presence of multiple erythematous lesions, was characterized by loss of filiform papillae which have the appearance of red spots in association with a subepithelial surrounded by a hyperkeratotic narrow white mononuclear inflammatory infiltrate, edge, with irregular, slightly elevated suprapapillary hypertrophy and vascular appearance.The lesions are located in the ectasia. The clinical examination and the mucosa of the dorsal face of the tongue, hard results of the histopathological examination and soft mucosa palate. In the tongue confirmed the diagnosis of Type 2 Migratory mucosa, the lesions have the appearance Stomatitis (Hume classification). typical for migratory glossitis (geographic As the patient suffered from burning tongue, marginal exfoliative glossitis or sensation, pain, and functional disorders, we annulus migrans) that appear as complex recommended a symptomatic treatment with: circinate patterns modifying their anesthetic mouth rinse, Vitamin A – topical, appearance in 24 hours [Fig.1,2]. antihistamine and zinc-based supplements Palatine mucosa presents the same lesional applications. We also recommended pattern but with slightly less shaped and avoidance of contact with local irritants, as faded appearance [Fig.3,4]. well as a diet avoiding acidic and spicy Most often, in case of localization of dorsal foods. face lesions such as a geographical tongue, the diagnostic certainty is based on anamnesis and clinical examination. Due to Discussion rare presence of lesions in oral mucosa areas Migratory stomatitis (MS) was first (palatine mucosa), we considered it described in 1955 under the term migratory necessary to confirm the diagnosis using the erythema that may occur in any area of the histopathological examination. mucosa[6]. It also has been known as Therefore, we are able to establish the geographic stomatitis, ectopic geographic differential diagnosis of these lesions by tongue, Cooke’s disease or migratory mucositis [2,7,8]. 56 Romanian Journal of Oral Rehabilitation Vol. 10, No. 4 October- December 2018 Main sites are: mucosa of the dorsal face of In case of psoriasis, oral mucosal lesions the tongue, jugular mucosa, and mucosa of have a similar appearance, and Weathers et the inner versant of the lips. Gingiva, al. in 1974 described the three types of alveolar mucosa and soft palate are rarely clinical entities: geographic tongue, involved topographic areas [9,10,11]. geographic stomatitis and intraoral psoriasis. Van der Wal N et al described the presence It characterized migratory stomatitis through of lesions in the palatine mucosa as a form of the following pathognomonic signs: manifestation of oral psoriasis and, to a migratory character, lack of painful lower extent, as a form of manifestation of symptoms and chronicity of lesions [18]. geographic stomatitis [12]. Ralls and Warnock even argued that The main location is the lingual mucosa with migratory stomatitis is a form of incomplete the appearance of geographic tongue. manifestation of psoriasis and Reiter’s Described for the first time by Reiter in syndrome [19]. 1831, geographic language (GT) is a chronic, In terms of lesion evolution, they tend to inflammatory disease that appears as an change their appearance and location in a individual pathological entity, or in the few minutes or hours. context of migratory stomatitis. The condition is characterized by periods of It is an immunologically mediated and of exacerbation and remission. In some unknown aetiology condition[4, 5,13]. patients, a lesional spike heals in two weeks, It affects between 0.6% and 4.8% of the and in other patients, it develops over several world’s population, and occurs more months [19]. frequently in children, and in adults, it is Regardless of the time frame, injuries are predominant in females [14, 15]. healed without any scars, and when The lesions change over time their location, recurrent, they have a new localization shape and size, affecting mainly two-thirds describing its migratory effect [14]. of distal dorsal faces and the lateral edges of Weathers et al divided the geographic lesions the tongue, as well as other areas of the oral into two sub-groups: erythema circinate mucosa in case of migratory stomatitis, in perstans and erythema circinate the way the cycle of lingual lesions ocurred migrans[18]. in the case presented above. Brooks and Balciunas showed that 34% of The literature in the field reports a low patients have a history of migratory lesions number of cases of migratory stomatitis. [5]. However, some authors believe that the When lesions have an atypical localization, incidence
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